Review of Brain On Fire: My Month of Madness by Susannah Cahalan

What is the value for doctors to read about the experience of illness? Certainly there is an abundance of books written by individuals who have suffered from assorted medical problems. If physicians conclude that the value is simply to remind them to be more sensitive or compassionate, they will miss the point of the extraordinary learning opportunities afforded by reading Brain on Fire.

Brain on Fire will undoubtedly create healthy anxiety in medical readers who will have to ask themselves the crucial question, “What would I have done if I had been in charge of this case?” Brain on Fire will be both humbling and frightening for the neurologist or psychiatrist reader. Clinicians will ask themselves how many of their own patients could have had an unrecognized neurological syndrome of the type incurred by Cahalan. Even we, the authors of a soon-to-be-released text on neurologic differential diagnosis, scrambled to ensure that this particular diagnosis was adequately represented. Yet, hoping to figure out the enigmatic diagnosis misses the more important lesson. We would argue that the best physicians are not necessarily the most savvy or knowledgeable; rather, they are the ones with humility who asks themselves the vital questions, “What else could this be?” and, “Should I get help?”

The initial symptoms experienced by author, Susannah Cahalan, were both neurological and psychiatric. Cahalan's experience early on with a psychiatrist who did not apparently inquire further about neurological symptoms might lead neurologists to feel justified in failing to bring in psychiatrists early in the evaluation of patients with altered mental status, out of concern that symptoms would be dismissed as merely “psychiatric.” This conclusion would be unfortunate since the broader concern is the frequent failure of neurologists and psychiatrists to communicate with each other. A better model of collaboration is demonstrated subsequently when the new psychiatrist appropriately states that bipolar disorder was a possibility, but only after neurological causes are excluded.

It was disturbing to read the description of the original outpatient neurologist who dismissed Cahalan's symptoms as a result of drinking and partying. While this attribution was particularly egregious because it was completely unfounded, the reader's demonizing of the neurologist will also block consideration of a broader issue that affects all of us. How often do clinicians latch on to diagnoses that seem easy to package and most probable, rather than taking each and every case and wonder, “What else could it be?” How often do we discipline ourselves to ask “Have we reasonably excluded other possibilities?” How many of us take the time to examine the broad differential diagnosis for each case we encounter before moving on to the next patient in a busy work day?

Furthermore, Brain on Fire poses a dilemma for all physicians who want to do well for their patients but find themselves practicing in a health care system that limits the amount of time which can be reasonably spent with each patient. Indeed, the emergency room physician evaluating Cahalan for a new-onset seizure followed typical clinical practice in discharging Cahalan after performing routine testing. Yet, taking more time to elicit a detailed history would have revealed her extraordinary change in mental status and that would likely have led to her admission and further investigations.

From another perspective, this book provides another fascinating reminder for the clinician of how patients who develop symptoms but who do not have medical training are unable to recognize their own need for medical care. As clinicians, we take it for granted that certain symptoms should be very alarming, but Brain on Fire reminds us how insidious the onset of illness can be and how severe symptoms may need to develop before a patient recognizes the need to get urgent attention.

There are other important lessons for the clinician reader. A classic error that continues to occur in outpatient and inpatient settings is the failure to have one doctor take charge and coordinate care among many different consultants. Part of the tragedy of Cahalan's illness was the initial lack of communication between neurologists and psychiatrists and how Cahalan and her parents searched for answers by independently going to different care providers rather than having one doctor take charge of her case and coordinate the investigation.

Brain on Fire focuses the reader's attention on the role of the healthcare providers. However, increasingly, we see educational initiatives to alert the lay public to the symptoms of a stroke or heart attack. Why is there such a paucity of public health alerts about symptoms and signs of mental illness, not only for the purpose of getting adequate attention to psychiatric needs, but also to get proper medical evaluations to exclude other potential medical underlying etiologies?

Cahalan idolizes her neurologist, Dr. Souhel Najjar, who not only uncovers the mysterious diagnosis but is an exemplar of compassion and humility. Perhaps some clinician readers may even experience jealousy, feeling that they are also worthy of recognition for their hard efforts on behalf of patients but were not lucky enough to be highlighted in a book of this kind. Why should patients perceive compassionate and thorough doctors to be the exception and not the rule?

It is likely that the primary readership of this book will be the lay public, who will receive an extraordinary education about neurologic illness while simultaneously being riveted by the story. Challenging concepts come to life with Cahalan's eloquence and clever metaphors (“The kiss of death of antibodies”). In fact, one wonders whether medical student and resident education would be greatly enhanced by supplementing traditional textbooks with books of this nature, which complement the dry lists of disease descriptions in formal texts with the real-life impact of illness.

We clinicians get frustrated with patients who do not follow our recommendations for treatment and rehabilitation. Cahalan also provides interesting insight into why patients may not adhere to their doctors' recommendations. As she explains, it is those individuals who are more aware of their deficits who may be less inclined to seek rehabilitation because this forces them to confront the reality and horror of their deficits. Paradoxically, those patients who are less likely to get better, may be less resistant to pursuing rehabilitation.

After recovering and in a potential cliffhanger moment of the book, Cahalan contacts the original arrogant neurologist, yet the reader may be disappointed with this portion of the story. The reader is dying to know whether he feels any remorse about dismissing her symptoms, or if he felt he learned any lessons from the story, yet she merely asks him if he had ever heard of her diagnosis. This is ironic because a few other physicians who undoubtedly worked very hard on her behalf during her hospitalization are ultimately portrayed negatively because of one misstep in communication. Yet, Cahalan lets the original neurologist off the hook by explaining his error as a consequence of our current medical system that requires doctors to see “35 patients” a day, rather than emphasize that there is simply no excuse for lack of humility and turning a deaf ear to patients' symptoms.

With all the current burdens and challenges of practicing medicine, it easy to lose sight of the meaning and value of the work we do. Reading books like Brain on Fire can actually be motivational and inspirational. Perhaps a small dose of books like Brain on Fire should be administered to clinicians before they go to the office each day; it could be very therapeutic.